Paradigm at First Colony

Inspectors wroteBased on observation, record review and interview the facility failed to ensure 7 of 7 residents reviewed for admission to the secured unit were free from involuntary seclusion. The facility failed to ensure Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10, whose assessments indicated they were low risk for elopement, had no evidence of history of elopement, had no physician's order for admission to the secure unit, had no IDT decision, were admitted to the secure unit with evidence of clinical criteria. The failures placed all residents on the secured unit at risk of not being assessed properly, not meeting the criteria to be placed on the unit., diminished quality of life and involuntary seclusion. 1. Record review of Resident #4's admission face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 2 of (Resident #2, Resident #3) of 3 residents reviewed for incontinent care. -CNA A failed to provide incontinent care in a timely manner for Resident #3. During incontinent care on 07/22/26, Resident #3's brief and draw sheet was heavily soiled with urine. -CNA C failed to clean Resident #2's perineal area one wipe at a time during incontinent care. These failures could place residents at risk for unwanted skin breakdown and infections. Resident #3 Record review of Resident #3's face sheet dated 07/22/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 07/12/26. Resident #3's diagnoses included: altered mental status, depression, and anxiety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident#1 Resident #2, Resident #3) of 3 residents reviewed for infection control. The wound care nurse failed to change gloves, sanitize her hands and place on a new set of gloves before applying a clean dressing to Resident #3's sacral wound. CNA A and CNA B failed to wash hands prior to providing incontinent care for Resident #3 on 07/22/26. CNA A and CNA B failed to don (put on) full PPE on 07/22/26 when providing incontinent care for Resident #3 who was on enhanced barrier precautions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (CR #1) residents reviewed for respiratory care. The facility administered oxygen to CR #1 without an order from the physician from [DATE] through [DATE]. This failure could have placed residents who received respiratory care at an increased risk of developing respiratory complications and receiving a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for rights. -The facility failed to ensure CR #1 was not left in a soiled bed after his colostomy bag leaked on the evening of 1/8/26.-The facility failed to ensure CR #1 was not left in a soaked bed of urine and tube-feeding formula after his g-tube leaked on 1/28/26. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure resident representatives had the right to exercise resident's rights to the extent provided by state law for 1 of 1 (Resident #1) residents reviewed for resident rights. The facility failed to ensure clinical records were provided to Resident #1's Power of Attorney (POA) as requested. This failure could place residents at risk of their needs not being met or disrupted continuity of care. Findings Included:Record review of Resident #1's clinical record revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Altered Mental Status, Unsteadiness on feet, Muscle Weakness, Lack of Coordination, Unspecified Macular Degeneration, Psychotic Disturbance Mood Disturbance and Anxiety. Record review of Residents #1's History and Physical dated 3/15/2025 revealed resident was Alert x3 and AMS was resolved. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents had the right to reside and received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and or safety of the resident or other residents for 2 of 12 residents (Resident #1 and #2) reviewed for resident rights. The facility failed to ensure Resident's #1's and Resident #2's call lights were within reach on 11/12/2025. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interview, and record review, the facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated, and that the results of the investigations were reported to the State Survey Agency within five working days of the incident for 6 of 8 residents (CR #1, CR#2, CR#3, CR#6, Resident #4, Resident#5 ) reviewed for Abuse, Neglect, and Exploitation. The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the allegations made on 12/26/2024, by CR #1 and CR#2, stating that CNA A provided rough care during activities of daily living (ADL) assistance. The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the family complaint made on 12/26/2024, regarding rough care provided by MA L during medication pass to CR#3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident, for 1 of 1 Resident (Resident #1) reviewed for medication administration. MA-A did not pull down on the lower eye lid prior to instilling medicated eye drops to Resident #1. MA-A placed the medication cap for the eye drops on an unclean surface, with the inside facing down then replaced the cap onto the bottle after administering the medication to Resident #1. These failures could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction, infection, or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident for 1 (CR#1) of 18 residents reviewed for anticoagulants. -The facility delayed sending CR #1 to a higher level of care on 11/21/2024 when CR #1 experienced an unwitnessed fall with a head injury (swelling to right cheek). CR #1 was receiving the medication Eliquis (blood thinner). -CR #1 was diagnosed with an Acute Subdural Hematoma with mass effect An Immediate Jeopardy (IJ) was identified on 11/23/2024 at 4:24PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 1 (CR #1) of 18 residents reviewed for accidents in that: - The facility failed to provide CR#1, who was on an anticoagulant medication, adequate supervision and interventions to prevent falls on 11/13/24, 11/14/24, 11/17/24, and 11/21/24 causing head injury and hospitalization. -The falls were unwitnessed, CR #1 had dementia and did not remember to use their call light when they needed assistance. Cr #1 was admitted to the hospital with diagnosis of Acute Subdural Hematoma with mass effect left craniotomy evacuation. An IJ was identified on 11/25/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 7 (#1, #2, #3, #4, #5, #6, #7) of 10 residents reviewed for personal privacy. The facility failed to ensure CMA A locked the computer screen, displaying the names of 7 residents, while CMA A was in a resident's room administering medication. This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. -The facility failed to post the daily nursing staffing information 11/14/24 - 11/19/24. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: Observation on 11/19/24 at 9:09 a.m., during entrance revealed the nursing staffing information was posted at the receptionist desk dated 11/13/24. Interview on 11/19/24 at 9:24 a.m., with the Staffing Coordinator, she said she was responsible for posting the daily nursing staff information at the front desk. She said she forgot to update it for the past few days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #37) residents reviewed for intravenous fluids. - The facility failed to ensure Resident #37 had physician orders and care plan in place for monitoring and dressing change of Resident #37's PICC line (Peripherally Inserted Central Catheter, a tube inserted through a vein in the arm which passes to the larger veins near the heart and used to deliver medications, liquid nutrition or other treatments) from when Resident #37 was readmitted from the hospital with a PICC line on 9/09/2024 to 10/2/2024 when the NP put in an order for the PICC line to be discontinued. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened or prepared and discarded after 72-hours (3 days) per facility policy. 2. The facility failed to store food off the floor in the storage room. 3. The facility failed to self-report to the local Department of Health for drain water backup in the kitchen, with less than a one-inch air gap. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen in the walk in refrigerator on 09/30/2024 at 8:15 AM revealed the following: 1. A plastic bag of boiled eggs not labeled. 2. A plastic bag of fresh salad not labeled. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #88 and #43) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #88's behavior of removing her oxygen cannula off her face and not properly storing the cannula when not in use. 2. The facility failed to care plan Resident #43 for potential skin issues due to being always incontinent with bladder and frequently incontinent with bowel . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #83 and Resident #205) reviewed for pharmacy services with 5 errors out of 33 opportunities from 2 of 2 staff (MA A and RN A) and a medication error rate of 15%. 1. The facility failed to ensure MA A administered Pantoprazole granules (medicine used to reduce amount of acid in teh stomach) mixed with 10 cc apple juice or applesauce per physician orders and Ferrous Gluconate (medicine used to treat or prevent low blood levels of iron) per physician orders for Resident #83 2. RN A failed to administer the following medications correctly for Resident #205: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to respect and dignity for 3 (Resident #78, Resident #70, and Resident #73) of 8 residents reviewed for respect and dignity, in that: 1. CNA M and MA J laughed while redirecting Resident #73 away from Resident #78 and #70. 2. CNA M and MA J called Resident #73 crazy while redirecting him away from Resident #78 and #70. This deficient practice could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse are reported immediately to the Administrator of the facility for 1 resident (Resident #91) reviewed for abuse. LVN M failed to immediately report her suspicions of abuse when notified Resident #91 was slapped. The deficient practices could affect any resident and contribute to further abuse or neglect.

Inspectors wroteBased on interview and record view the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Residents #91) reviewed for abuse and neglect. The facility failed to report an incident where Resident #91 reported to Family #1 she was slapped by CNA/someone at the facility on 07/13/2024 and 07/22/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered baseline admission care plan for 1 of 5 residents (Resident #43) reviewed for baseline care plans in that: -The facility failed to develop a 48-hour baseline care plan with goals, interventions, treatments, and psychosocial needs addressed in a resident specific care plan for Resident #43. This failure could affect new admissions residents reviewed for 48-hour baseline care plans of not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of six residents reviewed (Residents #60 and #155) for pressure ulcers. 1. The facility failed to provide resident with an air mattress bed as ordered by the physician from when he was re-admitted to the facility on [DATE] until the order was placed on 10/04/2024. 2. The WCN did not provide wound care to Resident #155 by cleaning the pressure wound and patting dry as ordered by the physician. This failure could place residents at risk for worsening of existing wounds or development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #155) reviewed for incontinent care. -The facility failed to ensure LVN C did not leave Resident #155's foley catheter ( (is a sterile tube that is inserted into your bladder to drain urine), on the bed with urine in the bag during pressure ulcer treatment. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #200). -The facility failed to ensure RN G used sterile technique during tracheotomy care and suctioning for Resident #200. This failure could place residents with a tracheotomy requiring suctioning at risk for respiratory infections, hospitalizations, and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 9 (Resident #88) residents reviewed for infection control. 1. The facility failed to ensure Resident #88's oxygen cannula that was found underneath two bedsheets and a blanket on her bed was properly disinfected before RN G placed the cannula in a plastic bag. Thisese failures could place residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster reviewed for food and nutrition services. -The facility failed to ensure the dumpster door was closed at all times when no one was dumping garbage . This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 5 residents (Resident#1) reviewed for accuracy of medical records in that: The facility failed to ensure that Resident #1's pain level was documented in the resident's clinical record. This deficient practice could affect residents whose records were maintained by the facility and could place the residents at risk for errors in their care and treatment.

Inspectors wroteBased on interviews, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #2 and #3) of 4 residents reviewed for accuracy and completeness. A. The facility failed to correctly note on Resident's #2's Facesheet that his race was White. B. The facility failed to obtain a psychiatric subsequent assessment (PSA) noting Resident #2's correct demographics. C. The facility failed to add Resident #2 and Resident #3's resident-to-resident altercation to the incident and accident report. This failure could place residents at risk of not having accurate and complete information available to those providing their treatment and care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have an adequately equipped system that allowed residents to call for staff assistance through a communication system for 1 (Resident #1) of 5 residents reviewed for call light button placement. The facility failed to ensure that Resident #1 ' s call light was functioning properly. This failure put residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 Residents (Resident #1 and Resident #2) reviewed for infection control. -The facility failed to label Resident #1 and Resident #2 personal care items -CNA A failed to practice hand hygiene while providing care and after care for Resident #2. This failure placed residents at risk for unwanted infections and decrease in quality of life.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for for 1 of 6 residents (Resident #2) reviewed for incontinent care. -The facility failed to provide Resident #2 incontinent care for over 3 hours. This failure placed resident at risk for skin impairment and UTI's.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 (Resident #4, Resident #5, Resident #6) of 6 residents reviewed for accidents, hazards, and supervision. 1. The facility failed to ensure safe smoking for Resident #4 when he had a lighter in his possession, outside of scheduled smoking hours unsupervised. 2. The facility failed to ensure safe smoking for Resident #5 when she had a pack of cigarettes in her possession, outside of scheduled smoking hours unsupervised. 3. The facility failed to ensure safe smoking for Resident #6 when he had a lighter in his possession and lit a cigarette for Resident #5 unsupervised. 4. The facility failed to ensure safe smoking for Residents #4, #5 and #6 while they were smoking, outside of scheduled hours unsupervised. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an accurate comprehensive person-centered care plan for 1 of 6 (Resident #5) residents reviewed for care plans. The facility failed to appropriately implement Resident #5 ' s care planned safe smoking goals and interventions when she had a pack of cigarettes in her possession and was smoking outside of scheduled hours unsupervised. These failures could place residents at risk for unmet care needs and decreased quality of care. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menus were followed for 2 of 2 observed meals in that: 1. Residents were not served milk at the breakfast meal on 9/5/2023. 2. Resident were not served bread at the noon meal on 9/6/2023. These deficient practices could affect residents who received meals from the kitchen by contributing to dissatisfaction, poor intake and/or weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. 1. Facility staff were using dishwashing machine to wash lunch dishes after it was found to not be dispensing chlorine sanitizing solution. 2. Facility staff did not document dishwashing machine temperature or chlorine sanitizing solution levels at lunchtime.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 2 of 5 residents (Resident's #14 and #60) reviewed for baseline care plans. -The facility failed to complete a baseline care plan within the required 48-hour timeframe for Resident #14 and Resident #60. This failure could place residents at risk for not receiving the necessary care and services or having important care needs identified. The Findings Include: Resident #14 Record review of Resident #14's admission Record form, dated 09/07/2023, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #13) reviewed for care plans. Resident #13 was not care planned for resting splint to right hand. This deficient practice could place residents at risk for not receiving appropriate care and services. The Findings Include: Record review of Resident #13's admission Record, dated 09/06/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for 1 (Resident #108) of 4 residents reviewed for respiratory care, in that: -Resident #108's Nebulizer mask was not changed in over 14 days. This deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Include: Record review of Resident #108's Face Sheet (undated) revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of garbage and refuse properly in that 2 (Dumpster #1 and Dumpster#2) out of 2 dumpsters had the lids open: 1. Dumpster #1 and Dumpster #2 lids were open. 2. There was refuse around Dumpster #1 and Dumpster #2. This failure could affect residents, staff, and visitors by placing them at risk for infection, pest infestation and decreased quality of life due to having an exterior environment which could attract rodents, insects, and other animals.